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3040 N. University Ave., Suite 2 Decatur, IL 62526 217-872-1700
Decatur Psychological Associates, P.C.
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    • Registration & Consent Forms
    • Release of Information Form
  • Home
  • Staff
  • Fee Schedule
  • Forms
    • Registration & Consent Forms
    • Release of Information Form

Registration & Consent Forms

1 Registration
2 Financial Policy
3 Insurance Information
4 Consents
5 Contact Information Form
6 HIPPA Privacy Policy
7 

  • REGISTRATION

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  • FINANCIAL POLICY

    • Patients are responsible for providing all demographic and insurance information at the time of service. Billing your insurance company is a courtesy and all balances not covered by insurance are your responsibility.
    • All office visit co-payments and co-insurance are due on the day of visit by cash, check or VISA/MasterCard. Until your insurance and deductible/co-pay amount can be verified you are responsible for the total payment of each office visit.
    • You are responsible to check with your insurance company to verify coverage and verify provider participation.
    • There is a $50 fee for completing disability forms, leave of absence forms, etc. Fees are payable prior to the forms being completed. Please allow 5 -10 working days for completion of forms.
    • There is a $20 fee for checks returned for insufficient funds.If an appointment is made and is not cancelled 24 hours prior to the appointment time, a $50 No Show charge will be applied to your account.
    • If your account is past due with no payment, it may be turned over to a collection agency. If your account is not paid in full and this account is turned over to a collection agency and/or attorney, then you agree to be responsible for all reasonable fees necessary for the collection of the delinquent account including, but not limited to collection agency fees of 50% of the balance due and costs and reasonable attorney’s fee of 33% of the balance.Please sign below if you have read and agree to the above policy.
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  • INSURANCE INFORMATION

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  • CONSENTS

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  • CONSENT OF TREATMENT:
    I authorize and consent to the performance of psychiatric treatment and/or testing considered necessary or advisable by staff associated with Decatur Psychological Associates, P.C.
    ASSIGNMENT OF BENEFITS:
    I hereby authorize direct payment of mental health benefits to Decatur Psychological Associates, P.C. for services rendered. I understand that I am financially responsible for any balance not covered by my insurance. I also understand that if this bill goes to collection and/or an attorney, I am fully responsible for all reasonable costs for collection and/or attorney fees that are incurred, as well as court costs.
    RELEASE OF INFORMATION:
    I authorize Decatur Psychological Associates, P.C. to release information including but not limited to; Medical History, Diagnosis, Mental Health Assessments and Progress Notesto any physician that may have referred me to this practiceor to any physician that I may be referred to by this practice.
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  • CONSENT FOR USE OF PROTECTED HEALTH INFORMTION (PHI) FOR TREATMENT, AND PAYMENT AND HEALTHCARE OPERATIONS:

    My “PHI” means health information, including my demographic information, collected from me and created or received by my health care provider, another health care provider, a health plan, my employer or a health care clearinghouse. This “PHI” relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

    I consent to the use of disclosure of my “PHI” for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations.

    I understand that diagnosis or treatment of me may be conditioned upon my consent as evidenced by my signature on this document. I understand I have the right to request a restriction as to how my “PHI” is used or disclosed to carry out treatment, payment or healthcare operations of the practice. My Provider is not required to agree to the restrictions that I may request. However, if she/he agrees to a restriction that I request, the restriction is binding.

    I have the right to revoke this consent, in writing, at any time, except to the extent that my provider has taken action in reliance on this consent. I understand I have the right to review my provider’s Notice of Privacy Practices prior to signing this document.
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  • CONTACT INFORMATION



    I authorize Decatur Psychological Associates, P.C. to communicate with the following people to confirm insurance or appointment information.
  • NamePhoneRelationshipEmergency Contact (yes/no) 
  • I further agree that a photocopy of this agreement shall be as valid as the original.
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  • HIPAA NOTICE OF PRIVACY AND SECURITY POLICY


    This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
    Our Company respects your privacy and understands that your personal health information is sensitive. According to the Health Insurance Portability and Accountability Act of 1996 (HIPPA), we cannot disclose your “protected health information” to others unless we have your permission –or unless the law authorizes or requires us to do so.
    The Health Information Technology for Economic and Clinical Health (HITECH) Act also requires us to notify you when the security or privacy of your health information is breached. Depending on the type of breach and how many individuals are affected, this many also involve notifying the media and/or government enforcement agencies, and keeping a log of all breach incidents.
    What is Protected Health Information? Protected health information (PHI) is individually identifiable information, maintained or transmitted through any medium. It relates to an individual’s past, present, or future physical or mental health or healthcare. Health information is individually identifiable if it either identifies you or another person by name and must be protected. Other identifiable information that must be protected includes address, Social Security number, dates of service, telephone number, e-mail address or vehicle identification number.
    Uses and Disclosures of Protected Health Information Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.
    Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
    Payment: Your protected health information will be used, as needed, to obtain payment for your health care services.
    Healthcare Operation: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of students, licensing, and conducting or arranging for other business activities. We may also call you by name in the waiting room when your physician or therapist is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
    We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required by Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal proceedings, law enforcement, coroners, funeral directors, and organ donation, research, criminal activity, military activity and national security, Workers’ Compensation, Inmates. Required Uses and Disclosures, for pre-employment physicals and to determine fitness for duty for the employee’s job, for requests for accommodation under the Americans with Disabilities Act (ADA), to administer leave under the Family and Medical Leave Act (FMLA) (where applicable) , or to comply with OSHA, MSHA and similar state laws. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164-500.
    Designated Record Set (DRS) Designated Record Sets (DRSs) become the repositories of protected health information that patients can access, amend, or restrict access to in exercising their individual rights. DRSs are the hard copy files we keep as well as electronic data sets.
    Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
    Your rights: Following is a statement of your rights to your protected health information.
    You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonably anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You must make this request in writing, and we may deny your request for certain information.
    You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members of friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
    Your physician is not required to agree to a restriction that you may request. If the physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare professional.
    You have the right to receive confidential communications from us by alternative means or at an alternative location. You have a right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e., electronically.
    You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
    You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserved the right to change the terms of this notice. You then have the right to object or withdraw as provided in this notice.
    Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.
    This notice became effective on April 14, 2003.
    We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our office
  • A copy of the HIPPA Notice of Privacy and Security Policy can be downloaded and/or printed from this website.
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  • RELEASE OF RECORDS


    This form is optional

  • Date Format: MM slash DD slash YYYY
  • Hereby REQUEST and AUTHORIZE Decatur Psychological Associates, P.C. to release/obtain the following information pertaining to my Substance Abuse and/or Mental Illness:
  • Release to / obtain from:
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    From
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    To
  • This information is being disclosed from records whose confidentiality is protected by one of the following state or federal laws. State law and federal regulation (42CFR part 2) and mental health and developmental disabilities confidentiality act (ILL. Rev Sate 1991. ch91 1/2 Par 801 ct seq.) which prohibits the redisclosure of any general authorization for the release of medical or other information is not sufficient for this purpose. I understand that I have the right to inspect and receive copy of the information that is disclosed.I understand that I can revoke this consent in writing at any time except as to disclosures already made. Unless revoked, this consent to release will expire on year from the date signed on...
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  • This is a continuing disclosure which covers the entire treatment episode and until all claims are filed and processed.

    I attest to the Identity of Signatory (is) below:
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  • If the Patient is 13 years or older they MUST also sign the consent
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